Provider Demographics
NPI:1568810513
Name:WAGNER, VERONICA HELGA (ARNP/CNM)
Entity Type:Individual
Prefix:
First Name:VERONICA
Middle Name:HELGA
Last Name:WAGNER
Suffix:
Gender:F
Credentials:ARNP/CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17001 COLLINS AVE
Mailing Address - Street 2:APT 1702
Mailing Address - City:SUNNY ISLES BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33160-3645
Mailing Address - Country:US
Mailing Address - Phone:408-319-0201
Mailing Address - Fax:
Practice Address - Street 1:2650 E BROADVIEW AVE
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-8302
Practice Address - Country:US
Practice Address - Phone:907-373-3420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-01
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK110376367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife